Cancers are of various types. However, breast cancer is one of the most common cancers. The World Health Organization says that almost 2.3 million women were diagnosed with breast cancer in 2022, and 670,000 died from the disease worldwide.
Oncologists who diagnose, treat, and manage this disease often struggle with its billing, leading to claim denials. This is why we have chosen CPT code 19125 for today’s discussion. It reports the removal of any malignant lesion inside the breast.
This blog discusses the comprehensive procedure that CPT code 19125 covers, along with some real-world examples, modifier applications, and billing criteria. So, let’s get to it!
CPT Code 19125 – Description
CPT code 19125 belongs to the ‘Ablation, Exploration, and Excision Procedures’ code range. It describes the removal of a lesion within the breast identified by a preoperative radiological marker through an open incision.
In simpler words, this process refers to the surgical removal of an abnormal area within the breast, which was identified through a localization wire (radiological marker) placed before the surgery (preoperative). The marker helps in removing the right breast tissue that is suspicious or abnormal. The objective of this procedure is to identify or rule out breast cancer, reduce symptoms, and prevent its spread to other parts of the body.
Scenarios Where CPT Code 19125 is Applicable
These are some real-life scenarios where CPT code 19125 can be applied.
Removal of Lumps Identified Via Mammography
Suppose a 30-year-old woman visits the hospital with a mammographic report where unusual lumps were identified inside her left breast. The physician decides to remove the lump. He opts for an open excision of breast lumps using a preoperative radiological marker. To collect payment for this procedure, he can apply the CPT code 19125.
Lumps Removal in a Patient with a Family History of Cancer
Imagine a scenario where a woman visits the clinic with a history of breast cancer in her family. Her mother recently recovered from breast cancer. Now, she is feeling lumps in her breast. So, she rushes to the physician to avoid any further escalation of the symptoms. The physician thoroughly analyzes her situation and decides to remove the lump via open excision of the breast lump. He uses a preoperative radioactive marker to identify the exact position of the lump. In this scenario, the physician can apply CPT code 19125 to bill for the procedure.
Lumps Removal in a Patient with a History of Tobacco Use
Tobacco and nicotine have serious implications for our health. According to Breast Cancer Research, women who smoked at some point in their lives had a 14% of developing breast cancer compared to those who never smoked.
So, let’s consider a scenario where a young girl in her early 20s with the habit of smoking visits the clinic with a lump in her right breast. The physician decides to remove the lump with an open excision biopsy. The process starts with giving local anesthesia to the woman. He inserts a wire (preoperative radiological marker) into the breast tissue before surgery to find the exact location of the lesion and proceeds to excise it. Therefore, he can use CPT code 19125 to bill for his services.
Applicable Modifiers for CPT Code 19125
Following is a list of modifiers, along with their descriptions, that may be applied with CPT code 19125.
Modifier 50
Procedures carried out on the left and right sides of the body during the same surgical session are reported using this bilateral modifier. So, if you removed lesions from both breasts during the same session, use modifier 50 with CPT code 19125.
Modifier 53
Modifier 53 describes a procedure that was initiated but was later stopped because of extenuating circumstances that jeopardized the patient’s well-being. So, you can append modifier 53 to CPT code 19125 if you began a surgical procedure (after anesthesia administration) to remove a lesion but stopped due to an unforeseen complication, like a nerve injury.
Modifier 59
Was the lesion removal distinct from other services you performed on the same patient on the same day? Apply modifier 59 to CPT code 19125.
Modifier XP
Modifier XP falls under the subsets of modifier 59. It represents that although the service was provided to the same patient, it was distinct because a different physician performed it.
Modifier LT
The physician must append modifier LT if the surgery was performed on the left side of the breast.
Modifier RT
The physician must append modifier RT if the surgery was performed on the right side of the breast.
CPT Code 19125 – Billing & Reimbursement Guidelines
The following are a few billing and reimbursement guidelines for CPT code 19125. These will help you reduce claim denials and reimbursement delays.
Ensure Correct Usage of the Code
It is essential to use the correct code according to the procedure being performed. Physicians usually get confused between CPT codes 19125 and 19120. The reason is that both codes are related to the excision of lesions inside a breast. However, CPT code 19120 specifically refers to the removal of a breast lesion, such as a cyst, fibroadenoma, or tumor, where attention to surgical margins is not critical. Whereas, CPT code 19125 deals with the excision of a single tumor with a preoperative radiologic marker.
Provide Appropriate Documentation
Your documents must support the medical necessity of the services you have provided to your patients. So, if you are conducting surgery for a breast lesion removal (CPT code 19125), you must attach mammographic reports or other reports that serve as evidence of the lesions. Furthermore, your documentation must provide correct information about the patient, from name to the medical procedure. All information should be accurate and confirmed by the patient.
Follow Payers’ Policies
The payer’s policy is another crucial consideration when billing for medical services because every patient has a different insurance plan. Before the treatment, you must confirm whether or not the payer covers the procedure you will be performing. Also, check what the reimbursement rates will be. Additionally, you must let your patients know that they are responsible for the bill payments if their payer does not cover the breast lesion excision.
Conclusion
To sum up, CPT code 19125, which reports breast lesion excision using a preoperative radiologic marker, is frequently used in oncology. We tried to address every aspect of this code, and we assume you are now more knowledgeable about it.
However, you can consider acquiring professional oncology billing services if you are still unclear or have trouble submitting error-free claims. These services save you time, lessen your administrative load, and connect you with expert billers.
